All right. I think most people are back, but we're going to go ahead and get started. I'd like to give Dr. Tereshevitz a little more time for her talk. She has been gracious enough to fill in for one of our colleagues who was ill and was not able to attend the meeting. I want to start by saying not only is she a pediatric neurosurgeon, but she's also a dear friend of mine and taught me a lot during the time that we worked together, especially arts and crafts and neurosurgery. Dr. Isabella Tereshevitz obtained her medical degree from the University de Sherbrooke in Canada and completed her residency training in neurological surgery at University Laval in Quebec City, Canada. She went on to complete a postgraduate fellowship in pediatric neurological surgery at Northwestern University Children's Memorial Hospital in Chicago. She is board certified by both the Royal College of Physicians and Surgeons of Canada and by the American Board of Pediatric Neurological Surgery. She joined the Department of Neurosurgery at the University of Texas San Antonio in February of 2015. She is an assistant professor and the medical director of neurosurgery at Northcentral Baptist Hospital. She specializes in pediatric neurosurgery. Her skill set focuses on the management of spinal dysraphism, congenital malformations of the central nervous system such as spina bifida, spasticity, hydrocephalus, intracranial arachnoid cysts, pediatric neurotrauma, pediatric neuro-oncology, vascular malformations, and epilepsy. And she's going to talk to us today about non-accidental trauma in the pediatric population. Please welcome Dr. Isabella Tereshevitz. Thank you. So we make a big deal when we get promotions, so I got a promotion. I'm an associate professor now, but that's it. You what? I'm an associate professor now. I'm not assistant. Didn't I say assistant? Yeah, no, you said assistant. That's okay. It's okay. That was a couple years ago, but that's okay. So I decided to talk about non-accidental trauma because I work in a level one trauma center. Most of you will see those cases when you work in one of your work settings, and most of the times we don't know what to do with those. We don't know how to recognize them, and then we just don't do much, and then those kids come back for a second time or third time, and some of them die. So I thought it was an important topic to discuss, and if it can give you more information about how you can help those patients and how you can do better, then great. So my disclosure, so I'm Canadian. That's number one, and I'm a hockey fan, and I have a very odd sense of humor in regards to politics. So that's my other disclosure. So the overview of this presentation, so first we'll discuss non-accidental trauma definition. We'll look at incidents and epidemiology. We'll look at literature updates, the most important articles that have been published in the last 10 years, and then what is our role in reporting, documenting, and protecting those kids. So the definition of non-accidental trauma, according to the CDC, it's an injury to the skull or intracranial contents of a baby or a child that's under 5 years old. Child physical abuse that results in an injury to the head or the brain. So non-accidental trauma is inflicted injury. The other name that we use commonly is abusive head trauma, so abusive head injury or inflicted traumatic brain injury. So you will see those terms interchangeably. There has been a shift in terminology in the past 10 years, so we don't use shaken baby syndrome anymore because it implies that someone has shook the baby, and we don't know what happened because we weren't there, so we don't use shaken baby syndrome anymore. We kind of use it, we imply it, but we shouldn't be using this in our notes, in our progress notes or in op notes because in court it will not be a great idea. So we use more general terms, and it has less legal ramifications. So we use abusive head trauma most of the times. It's more general terminology. The epidemiology in 2008, the annual incidence was between 17 to 19 per 100,000 person per year for children under 2 years of age. In 2010, the CDC reported 2 per 100,000 children dying due to abuse or neglect. In 2002, an estimated 1,400 children died due to maltreatment in the United States, and abusive head injury was 80% of those cases. So the leading cause of death in this patient population is non-accidental trauma. It's not uncommon. In 2014, the estimated incidence was 16 to 33 per 100,000 infants per year. Abusive head injury is as prevalent as neonatal meningitis. So I really want you to just remember this. It's as common as meningitis. What are the outcomes of abusive head injury? So 20% of those kids, when they show up to the ER, will die. One-third will be severely disabled. One-third will be moderately disabled. And one-third will have no symptoms or very mild symptoms and will recover well. What are the risk factors for non-accidental trauma? So mainly it's kids or a child that's under 3 years of age that's pre-verbal. Some series report mainly under 2 years of age. And the risk is inversely related to age. The risk is higher in male children. Black children have greater risk of mortality from non-accidental trauma. And then preemies or having multiple medical comorbidities puts you at higher risk of non-accidental trauma. Who are the perpetrators? So it's young parents. Young males are more likely to be responsible for non-accidental trauma resulting in death. The eldest child or a second child in the family has the highest risk of abuse. And then alcohol in the family, drug abuse, psychiatric disorders, history of violence, jail sentencing, or a previous child being withdrawn from the family is a higher risk for those perpetrators. And then there's a doubling of rate of non-accidental trauma during economic recessions. This is a table just summarizing the risks of abusive head trauma in children. So this is an interesting article that was published in 2008. Another one. The demographics of non-accidental trauma. So 28.2 for every 100,000 infants will suffer inflicted head injury within the first year of life. So the younger kids, it's even more prevalent. The mortality rate is 21.4%. The perpetrators, 37% fathers, 20.5% boyfriends, 17.3% female babysitters, and 12% mothers. The risk factors, young parents, unmarried, less educated, low birth weight for the child, less prenatal care, and being from a minority group. Then who are the kids that we miss? What are the cases that are missed? So the Children's Hospital in Denver, Colorado, looked at their cases from 1990 to 1995, and they figured out that they missed 31.2% of cases that were abusive cases. And who were those kids? And it took seven days from initial presentation in the ER to diagnose those kids correctly. And who were those kids? Very young, white children from intact families. And also children that presented without respiratory compromise or seizures. So the white child that came from a normal-looking white family, we didn't suspect them. 40.9% of missed cases experienced medical complications related to delay in diagnosis. What I want you to remember is four out of five deaths might have been prevented if only we recognized those signs and symptoms early on. What are the signs and symptoms of non-accidental trauma? So due to the incidence, which is high, 16 to 33 cases per 100,000 children per year in the first two years of life, you need to have a high suspicion if you have neural signs and symptoms and no trauma described. What is very specific for kids? And this applies until mid-childhood. So the skull is very thin. There's very little protection against impact. The head at that age represents 15% to 20% of the body weight, compared to our heads, that is only 2% to 3%. Brain, the consistency is soft to high water content, and there is also immaturity of myelination, which puts them more prone to injuries and shearing injuries. A young child's brain is more easily damaged by strains and shearing forces. And there's also smaller subarachnid spaces, which has less protection and less buttress support. The neck is also very weak in kids, so the muscles are weaker and the head is heavier. What are the mechanism of injuries? So it's either static versus dynamic, focal versus diffuse. Now the killer combo in kids is dynamic-diffuse injuries. And then one thing that I really want you to remember, because if you do see a lot of those cases, you listen to the crazy stories that those parents or whomever tells you about, and it's always some funny story about how, I don't know, a book fell on the kid, or the brother fell on the kid, or something that doesn't make sense. But sometimes it's a crushing injury. So crushing injuries, according to the literature and all the research that has been done, is a static injury, which means that something fell on the kid's head, and so the stationary head is compressed by a heavy object. And most of the time it's going to be a fracture of the skull. Crushing injuries occur slowly. It doesn't create any shearing forces. It's not a diffuse injury. Brain injuries are focal rather than diffuse. And in cases where it's not like a heavy object that crushes the head and the kid dies, most of the crushing injuries are nonlethal, and the patient is completely awake when this happens, and the lesion or the brain injury is very, very focal. And there's no rotational component to the injury, so there's no diffuse axonal injury, there's no swelling. So it's a very simple injury. A crushing injury is a simple injury. Shortfalls, that's another funny story that they tell you. Okay, shortfalls occur around the home and are rarely fatal. A focal contact injury to the scalp creates a small contusion or a laceration or no injury at all. So in 1 to 3% of shortfalls, you can have a small linear skull fracture without intracranial injury. So a shortfall from, let's say, a stool or a small bench will at most create a small skull fracture. You won't have diffuse axonal injury with subdurals and a couple of, you know, lobes. You won't have that. So a shortfall is simple also. And if you have intracranial injury, you have an epidural hematoma most of the time, or a very focal subdural hematoma, and both our toes are located at the injury site. Yes? Yes, but depending on the baby's age, a two-week-old doesn't roll out of bed. Yeah, but that's the other funny story that we hear. Yeah, yes, so yes, and depending on what is the surface that they fall onto, yes. And at the end of the presentation, I will show you what kind of injuries create, like, are lethal. So you kind of see the difference between this and what really happens when it's dramatic. So there's little deformation of the brain in shortfalls, and there's no diffuse brain injury. This is also a very interesting article that discusses clinical presentation. So what is the presentation of non-accidental trauma? So most of the time, it's irritability, poor feeding, vomiting in 15% of the cases, and then developmental delay, just so you can think about this, it's not a one-time thing. It happens often enough that they have delays in their milestones. Lethargy in 77% of the cases, respiratory compromise, seizures in up to 50% and apnea. What are the physical findings? Scalp injuries, skull fracture, intracranial hemorrhages, diffuse axonal injuries, cerebral edema, cervical spine fractures, cervical spinal cord injuries, retinal hemorrhages, rib fractures, long bone fractures. The most common clinical features, subdural hematomas in up to 90% of the cases. If it's interhemispheric, it's more commonly correlated with abusive head injury. And then retinal hemorrhages can occur in up to 82% of the cases, and the importance of the description of those retinal hemorrhages is so, I mean, I can't focus on that enough. You can't just say, oh, there's retinal hemorrhages. You need to describe the location, how many, in the periphery or not. So that's really important. So you need to have opto involved early on. This is a list for the differential diagnosis of subdurals and retinal hemorrhages, just so you have a list of what can cause those injuries. Retinal hemorrhages. So if you see retinal hemorrhages like these, those are nonspecific and they are mild. For sure, you can have a bunch of different causes, you know, creating this, but when you have something like this, this is something typical of an abusive case, nothing causes this. I mean, you could have a horrendous car accident, but your face doesn't look normal and the rest of your body doesn't look normal. And in abusive cases, they look normal and they have those retinal hemorrhages in their eyes because someone shook them out of them. So this, when you see this in pictures in someone's chart, you pretty much know that this was an abusive case. So severe retinal hemorrhages are not pathognomonic for abusive head injuries, but they're highly specific. And the pattern of retinal hemorrhages is strongly associated with abusive cases. So it's large in numbers, both eyes, and involves all layers of the retina, and it extends in the periphery. So this is a slide that shows you what happens in an accident and what happens in an abusive case. So in an accident, you could have, you know, some significant hemorrhages, but you don't have the flames, the pearls, and the diffuse hemorrhaging. When you have all of those combined, it is an abusive case. The American Academy of Thermology published this article in 2010. So you have retinal hemorrhages in 85% of cases when you have some sort of shaking injury type. And they use shaking syndrome because they did not read our literature, but we shouldn't be using that terminology. So rarely you will find retinal hemorrhages without an intracranial hemorrhage. And the one thing that you need to know is those retinal hemorrhages will resolve very quickly. So whenever you have a suspicion of a child that is abused, get opto involved quickly. So when you see them in the ER, call opto so they can be seen right away, because if you wait a couple of days or if you schedule them to be seen as an outpatient, those retinal hemorrhages will have most probably disappeared. And so, yes, retinal hemorrhages cannot be dated, but as soon as the patients are seen and you can take a picture and leave that in the chart, that's better than having no documentation at all. You can also have retinal disruption. And then the one thing that you need to understand is that those kids have retinal hemorrhages, but they don't have any evidence of trauma on their bodies. I mean, rarely do they have amazing bruising on their bodies that would be suggestive of any additional, you know, trauma. Extensive retinal hemorrhages are rarely seen in critically ill patients. And if you have retinal hemorrhages that are present in a motor vehicle accident, they're rarely extensive and they're most of the time confined to the posterior pole only. So retinal hemorrhages, as I said, may start to resolve within the first 24 hours. That's why it's important to have clinical notes that describe the number, the extent, the pattern, and the type of laterality. And if you don't have an ophthalmologist that can take pictures, at least ask them to make drawings so you have some description of what kind of retinal hemorrhages you have for that patient. And then documentation with pictures is the most important thing. You can also have some post-mortem protocols that are in your hospital that can be done. That's pretty much it. Other signs. So cervical spine injuries are also underreported in child abuse. C-spine injuries can occur up to 44% of those children in affected trauma. So I can't tell you that there's something that routinely you need to be looking for, but be aware that you need to check the C-spine. So how can we predict non-accidental trauma? And that was my warning. I have a very odd sense of humor about politics. That's the million-dollar question. I'm Canadian. There are things I don't understand. Sorry. And I live in Texas, so I'm super confused lately. And I'm dating a Republican. Sorry, TMI. We've been friends for a long time, so it's all good. Okay, so how can we predict non-accidental trauma? So this group here tried to find a way to be able to help clinicians predict which case is an abuse case or not. So it's a group from the U.K., and they looked at their annual incidence of abusive cases, and it's slightly lower than what we have here in the United States. So for children under 2 years of age, their incidence was 12.8 to 17 for 100,000, and in the younger group it was higher. So they looked at the triad, the old triad for shaken baby, like 20 years ago. This is what we described, the retinal hemorrhages, the subdural hematoma, and the seizures. And they wanted to find a way to predict a tool or to have an algorithm that would recognize those cases, and that's what they did in 2011. And then they validated their algorithm in 2015. And so here are the results. So they looked at 1,053 cases of children with intracranial injuries, and the injuries were subragnant hemorrhages, epidural hematoma, subdural hematoma, interparenchymal hemorrhages, contusions, DAI, hypoxic injuries and ischemia, retinal hemorrhages, long bone fractures, seizures, apnea, and head and neck bruising. And in all those kids, they had 348 abusive cases. So the patterns of injury, what they were able to find, if you have a subdural hematoma in a child that's 2 years and younger, the high probability of this being an abusive case if the subdural hematoma is interhemispheric and if it's over multiple convexities or if it's bilateral. It's suggestive of an abusive case if the MRI shows hypoxic or ischemic injury and diffuse axonal injury. And specific patterns of retinal hemorrhages are suggestive of abusive cases. Boys are more affected than girls. Abusive cases happen in more younger patients. Rip fractures and long bone fractures are highly indicative of abusive cases. And apnea had a stronger association with abuse than seizures. And so, this is the slide that I thought was so good for people in the ER understanding those cases. So, if you have a child that has intracranial injury alone, with possibly a suspicious story, and the child is younger than three years of age, what is the likelihood of this being an abusive case? It was 4%. If the child presents with intracranial injury and retinal hemorrhages, the likelihood of this being an abusive case is 58%. If you have intracranial injuries and bruising of the neck, it's 15%. If you have intracranial injuries, neck bruising, and apnea, it's 54%. Intracranial injuries, apnea, and retinal hemorrhages, 90%. Apnea and seizures, 58%. Seizures and rib fractures, 90%. And I mean, I didn't know this, and I see them often. So, I thought that this article was really, really good for you should see the stuff that I see. It's just amazing. But seizures and rib fractures, there's nothing neurosurgical in that. I mean, most of the times they would be calling neurology, and it's a case of child abuse. So, when you have three features or more that were present, the positive predictive value was 85%. Rib fractures and retinal hemorrhages are the most discriminating, and so for them, the importance of standardizing that was really their goal. And so, they did that in 2015, and they looked at something prospectively. They looked at 198 cases that were just admitted randomly consecutively in their ER, and they had 133 non-accidental cases, 65 accidental cases, abusive cases, I'm sorry, non-abusive cases, 133, and abusive cases, 65, and it was kids that were under three years of age with intracranial injuries. And the items that they were, the boxes that they wanted to check was retinal hemorrhages, rib fractures, long bone fractures, apnea seizures, and head and neck bruising. And so, the more at-risk group was the younger than two years of age. They had 33% of abusive cases, two-thirds were boys. When they had three or more of the six features, the probability of this being an abusive case was 81.5%. So, the screening tool for them, if a child presented with acute respiratory compromise before the admission in the ICU and an intracranial injury, it was highly suspicious of abuse. If they had bruising of the torso, the ears, and the neck, it was highly suspicious of abuse. If they had bilateral or interhemispheric subdural hemorrhages or collections, it was highly suspicious of abuse. Any skull fracture other than an isolated parietal fraction that could be from a baby rolling out of bed, if they're older than, let's say, six, seven months because they're able to roll in bed, then it was highly suggestive of abuse, or at least they would call CPS and they would do the investigation. So, patients meeting more than one of those criteria were considered at high risk of abuse and they would just start the workup for abuse at that point. I'm going to possibly skip this really quickly, but this is another interesting article. They looked at all the possibilities of all the fractures, not only cranial fractures, but also body abnormalities, and they looked at what is the difference between the abuse group and the non-abuse group. What they found is that in the age difference, there's no big difference in age, but that the abuse group, they had more cerebral ischemia, more retinal hemorrhages, skull fractures, and then long bone fractures, and the accident group only had epidural hematomas, I said skull fractures, and scalp swelling. So, when it's a real accident, it's as simple as that. Epidural hematoma, skull fracture, scalp swelling. There's nothing else, like, you know, I don't know, long bone fractures, seizures, apnea, distress, whatever, that doesn't exist in a simple accident that happens around the household. So, this is the article that I was referring to earlier on. They looked at all the deaths that happen around the household, and so, 163 deaths. They looked at what happens when a child dies around the household. So, 39% are accidents, 58% are asphyxial deaths, 16% are head injuries, 11% intoxications, blah, blah, blah, blah. And so, they looked at the head injuries. So, this is what I want you to remember, the magnitude of the head injury that causes death is significant. So, four were struck by some object, and it's not a small book, or a child, or I don't know what, it's like a lawnmower, or a heavy pole, or I don't even know, a metal, whatever, something that destroys the head. And then the falls, or falls from like a second story, a ninth story, 13 steps in a walker, so imagine the velocity of the fall, and then 10 steps in a toy cart, so that's another fall that's significant compared to falling from the bed, or falling from a stool. So, the injuries were two skull fractures with acute subdural hematomas, two penetrating injuries, and six massive crushing injuries with skull fractures and brain lacerations. That causes death. Not the fall from the bed. Not the whatever they can tell you in the ear happened to their kids. Not because the sister was holding the kid and fell on top of the kid, and then the toy fell on top of the kid and the other kid. Most accidental child deaths in and around the home result from asphyxial events. Difficulties when there's a head injury, is it an accident or is it inflicted, but keep in mind the previous slide, it has to be, the magnitude of the injury has to be severe to cause death. So, inflicted trauma, I'm not sure I want to discuss this, I just want to go, okay so as a reminder, the eye exam, so the retinal hemorrhages are important, we find retinal hemorrhages in 80% of the cases that die, large in numbers, too numerous to count, multiple layers, rarely do you have retinal hemorrhages when you do CPR on a patient. Because someone will tell you, oh, it's because the child had CPR when they stopped breathing at home, EMS came, they did CPR, that's why they have retinal hemorrhages. That doesn't happen. And even in very severe motor vehicle accidents, you can have extensive retinal hemorrhages, but not to the extent of the ones that I showed you initially. So what is our role? Any person that has cause to believe that a child's physical or mental health has been or may be adversely affected has to report to Child Protective Services. And so I have information on how to do this in Texas, but wherever you are practicing, please be aware that there are numbers that you can call and leave messages and report those cases. And then someone will, so CPS will come back to you and they will investigate. So what happens is that they validate the reason and then they implement a safety plan. And the timeline is within 14 days. And then there's some court, you know, steps and stuff like that. So our role is to make this process clear and as simple as possible on our end. So what I want you to remember from this is that we need to use the right terminology in our charts and in our progress notes and in our op notes. And so I will give you an example. So this is a case that happened to us last year. A two-year-old that was otherwise healthy was admitted to our university hospital after trauma of unclear ideology, had a huge right subdural hematoma, was reportedly presented in cardiopulmonary arrest and had CPR done and was intubated in the field. And then he was supposedly in the care of the mom's boyfriend. That's the other story that we got. Two-year-old, previously healthy male, says post-cardiac arrest, concerned for non-accidental trauma. Per report, the incident occurred at 5 o'clock in New Valdez. Child was in the care of mom's boyfriend. Mom wasn't there. She was working somewhere else. And then there's two different stories, one that the child was eating cookies and then he was found later unresponsive, and the second one that the child fell. So EMS came, intubated the child. He was GCS3. He had abrusions and contusions on his body. This is the subdural hematoma with the massive swelling in his brain. So what I do now is I go to the OR and I take pictures and I have videos and I upload this in the patient's chart, because I know that those cases will go to court. And sometimes my description of the operative report is not enough for the judge to understand that this is an acute subdural hematoma, so I have pictures and I have videos now in the chart. So this is clearly acute. And I also dictate specific things. And I guess I like booze, because I described it as sangria-colored. I don't know. But I do specific things. So when people that are not in the medical field read this in court, they understand what's going on. So what I want you to remember is whatever you put in the chart, be careful about the terminology that you use, and it has to be simple and nonjudgmental. So Opto, what they said is that he had retinal hemorrhages, and then the child died. That's another case that had a significant skull fracture that needed to be elevated, so I took pictures and I put it in the chart. And then since we have so many of those cases in our institution, we have started a checklist, and that has been something that we implemented in 2015, a couple months after I started my job there. It was so traumatized by the amount of kids that came through the ER. And so we have this checklist now, and we call Opto the minute that they hit the door and we have a suspicion that this is abuse, Opto comes and they take pictures and it's uploaded in the chart. So be highly suspicious when you have, that's one of the pediatricians that works with us sent me this. It's called the Dirty Dozen. It's all the crazy, crazy, crazy stories that parents or whomever takes care of the child will tell you about what happened. So when the story is that the child fell from a low height, such as the crib, couch, bed, and chair, and you have significant brain injuries, or that the child fell or struck his head on the floor, on the furniture, or that he was found dead in the crib. Like I put the baby to sleep for a nap, and I came back and the baby was dead. Child choke while eating, and then they had to, you know, try to resuscitate, whatever, and they were shaking the baby. I mean, the stories that we hear are a little crazy. And then another child, I mean, you have a list of 12 little crazy, you know, reasons why they show up in the ER. And then when milestones don't add up, because they will have significant developmental delays, when milestones don't add up, be suspicious. So those are just milestones. And then also abuse and neglect. So sometimes we don't think about, you know, a child being maltreated because it is not abuse, but it's neglect. So this is another example that I had recently. And neglect is really disgusting, but okay. A six-year-old was a passenger involved in a shooting. So parents were in the car. The parent's car was shot by an unknown person in a parking lot. Parents recently moved from Florida because schooling system, as they said, for their girls was better in San Antonio. That's where I live. And so they were looking for an apartment with a five-year-old and a six-year-old in their car at 9 p.m. The five-year-old sister was also in the back seat. The six-year-old previously healthy female admitted to the ICU status post gunshot wound to the thoracic spine with a bullet lodged in her spinal canal at T6. Her mother, a patient, was riding in the back seat of the car with the family. The family was driving from the store and got lost after taking a wrong turn. That's the second story, because initially they said they were looking for an apartment. They pulled into an apartment complex to turn around. From there, a man got in his car, started following their car, and began shooting at them. The patient cried out that she was shot. No one else in the vehicle was injured. The mother states that the bullet came through the trunk of the vehicle, through the patient's seat, and hit her in the back. So this is the scan for that patient. And so initially we just thought that it was an accident. But very quickly I was suspicious of the story that kept changing. And then the mother looked like she was on some sort of drugs. And I guess I watched some crazy thing on TV where people that are on meth have yellow teeth, and I thought she had yellow teeth. So I called the people, and they tested her, and she was a meth addict, whatever. So just to tell you that you always have to be suspicious, this was a case of negligence. And it didn't end up in a brain injury, but the poor child is now paraplegic, but is not with that family anymore, and has been in a foster family, so it's good. So we can make a difference if we are suspicious enough in making a diagnosis early, in helping CPS and in a multidisciplinary team to help those kids. Documentation is the most important thing. And then also reading the most updated literature. And then I'm going to leave you with this. This is, these are the crazy theories that people come up with in court, that normal healthy infants die suddenly many months after birth because of birth-related subdural hematomas that rebleed spontaneously after minimal trauma. Another theory is that subdural hematomas in infants are caused by episode of hypoxia. Unexplained subdural hematomas in infants can be the result of venous sinus thrombosis. Subdural hemorrhages in infants are caused by immunization, same thing as autism, I guess. The signs and symptoms of abusive head trauma can actually be caused by benign extractal fluid of infancy. Short falls can cause signs and symptoms of abusive head trauma. Retinal hemorrhages are not indicative of abused head trauma. Biomechanical studies have proven that violent shaking of infants does not cause serious head injuries. Any questions? So, you know, as providers, we are required by law to report any suspicious accidental trauma or non-accidental trauma to the authorities. So I know, I know, I personally, when I go down to the ED, you know, you always kind of look at the parents and you get either a warm, fuzzy feeling like, oh, these parents would never do that, or it's like, oh, yeah, yeah, I know what you did. But you know the warm, fuzzy feeling? The white kid that Denver studied, I think it was like 32 percent of those white kids that we have the warm, fuzzy feeling towards those parents are still abuse cases. So I have no warm feelings towards anyone anymore. Well, maybe my Republican boyfriend, but. No. I had probably one of the worst cases shortly after I got to Massachusetts when I was at Bay State, and this was actually an older child. She was eight years old and was repeatedly going to school, and it actually ended up being the elementary school that my kids went to, and they weren't there yet. And this child would come in covered with bruises, black eyes, you know, sometimes would wear sunglasses in, and the teachers, the teachers did not do anything. The mom would go in and say, well, she's clumsy, she falls, she's this, she's that. Well, the stepfather ended up beating her so badly that he would make her stand downstairs in a thing of ice-cold water in the basement. The abuse and neglect was so terrible. At any rate, he beat her so severely one night that she was brought to the local hospital and then transferred down to the PICU. Didn't think that she was going to survive, and this was just a total case of everybody looking the other way from the teachers, and the mother actually wrote, kind of wrote like she was writing in the child's handwriting to cover up that she had wanted to kill herself and that she threw herself down a flight of stairs and that she had written this letter. But it shook our community so badly, because it was in all the newspapers and everything. It just shook the community so badly and made it, you know, I mean, it's not just the health care providers, but it's teachers and clergy and so many people that could report these things that are going on, because you can't turn a blind eye to kids that are coming in bruised or look malnourished or dirty, disheveled. It was just a horrific case, and she never recovered from her head injury, and she lives in a long-term care facility. And interestingly, a couple weeks later, her mother and her grandmother both came in with gunshot wounds to the head. The mother, the grandmother, tried to stop the circle of abuse and so shot the mother, and shot herself. So the mother and the grandmother were now out of the picture, which left the stepfather, who didn't want us to turn off life support, because that meant he would face a murder charge. And so we had to have hearings at the bedside with the judge in front of this child. I mean, it was one of the worst cases of abuse I had ever seen. Cigarette burns, and it was terrible. And the judge said, no, we could not turn off the life support, and eventually we weaned her off the ventilator. And she's pretty vegetative. So that was 13 years ago. So she's now a 20-something-year-old female living in a long-term care facility. And it all could have been prevented. The rationale for not reporting it? Because it would have been a capital murder charge. And so the judge said what we could do was we could wean her, and then there would be no, if she stopped breathing, we would not re-intubate her. But she was able to. We pulled the tube, and she was breathing on her own. So she was never brain dead. She was just a low GCS. But the moral of the story is it was missed on so many levels. It was missed by her own pediatrician when she would go in. It was missed by the teachers. And not missed, I think some of them turned a blind eye to it. Because you don't want to accuse a parent. And I know how, when you go down to the ED and you see this kid that's obviously been abused, to restrain yourself and not want to rip them apart? I'm good at that now. So what I want to say is that what I say now to parents, any parent, I just say this is our protocol. And we do this because it's so prevalent. It's as prevalent as meningitis. So we just have to do this. We just have to X the box and make sure everything is safe for this child. And if we save one child, it's great. So that's what you just do. You just do your best. All right. Any other questions? All right. Thank you.

non-accidental trauma

pediatric population

skull injuries

physical abuse

recognizing cases

incidence

risk factors

multidisciplinary approach